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<br /> I <br /> CERTIFICA nON OF COMPLIANCE I <br /> MINNESOT A WORKERS' COMPENSA nON LAW <br />Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold -- <br />the issuance or renewal of a license or permit to operate a business or engage in an activity in <br />Minnesota until the applicant presents acceptable evidence of compliance with the workers' <br />compensation insurance coverage requirement of Chapter 176. The information required is: I <br />the name of the insurance company, the policy number, and dates of coverage or the permit <br />to self-insure. This information will be collected bv the licensine: ae:encv and retained in their <br />files. I <br />This information is required by law, and licenses and permits to operate a business may not <br />be issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this I <br />information is not provided or falsely stated, it may result in a $2,000 penalty assessed against <br />the applicant by the Commissioner of the Department of Labor and Industry. <br />Insurance Company Name: A In t' VI (' (I 1/\ l:; n, ;j7 d -tN :Sll n:l/J (p I <br /> (l:':!OT the insuran e agent) I <br />Policy Number <br />Dates of Coverage: to I <br /> (or) ~ <br />I am not required to have workers' compensation liability coverage because: <br />( ) I have no employees I <br />( ) I am self-insured (include permit to self-insure) I <br />( ) I have no employees who are covered by the workers' compensation law (these include: ' <br /> Spouse, Parents, Children and certain farm employees) I <br /> -...?<...- <br />I certifY that the information provided above is accurate and complete and that a valid workers' I <br />compensation policy will be kept in effect at all times as required by law. <br />Name: f{ G /I; '5001 I <br /> (last, first, middle) <br />Doing Business As: Ar'f"a-1 r/;;h,,:i{ f2 O-.\?t" rr::; ,;1- aye I <br /> (business name if different than your name) <br />Business Address: 'l, r 4- f J\i D j HI l~. )(; . \]to " IJvr;, I <br />City, State, Zip: Po.\1.A.-" \-\-',f( r M tvS' Sil2 Phone: (f> (2) UR f - 51 I 0 () .. <br />Signature: "Ok 9kf Date: '1- (0 -q7 <br /> I <br /> --- <br />